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Leaving ArkansasBlueCross.com

By selecting "Continue," you will be exiting the Arkansas Blue Cross and Blue Shield (ABCBS) website. If
you choose to access other websites from this website, you agree, as a condition
of choosing any such link or access, that ABCBS is not and shall not be responsible
or liable to you or to others in any way for your decision to link to such other
websites. You further agree that ABCBS and its affiliates, its directors, officers,
employees and agents ("the ABCBS Parties") are not responsible for the content of
any other website to which you may link, nor are ABCBS or the ABCBS Parties liable
or responsible under any circumstances for the activities, omissions or conduct
of any owner or operator of any other website. Once you choose to link to another
website, you understand and agree that you have exited this website and are no
longer accessing or using any ABCBS Data. You understand and agree that by making
any third-party website link available as an option to you, ABCBS does not in any
way endorse any such website, nor state or imply that you should access such website
or any services, products or information which may be offered to you through
such other websites or by the owner or operator of such other websites. The owners
or operators of any other websites (not ABCBS) are solely responsible for the content
and operation of all such websites. ABCBS makes no warranties or representations
of any kind, express or implied, nor of merchantability or fitness for a particular
purpose, nor of non-infringement, with regard to the content or operation of any
other website to which you may link from this website.

Job SummaryThis position is responsible for case management (excluding Behavioral Health) initiating a collaborative process which assesses, plans, implements, coordinates, monitors and evaluates the options and services required to meet an individual's health needs, utilizing plan benefits and community resources. The incumbent will utilize communications and available resources to promote quality and cost effective outcomes.

Nature & ScopeThe incumbent's charge is to work with referrals from multiple sources to identify appropriate candidates for case management.

Member
The incumbent will facilitate formation of health care teams to include patients, families/caregivers, physicians, and all other ancillary providers. Incumbent must have the ability to communicate at all levels, often in a highly charged, emotional environment. This incumbent should be a highly detailed professional who can work well with other health care personnel and interact well with patients and their families.

This position works closely with the Team Leaders, Supervisor, and Management for the implementation of medical management programs for all BANA business.

Minimum Job Requirements

1. Arkansas Registered Nurse with current license and in good standing with clinical practice experience.

2. CCM Certification required. If certification not obtained prior to employment, must sit for exam after 12 months of employment. If not passed on first attempt, must re-test and pass within 2 years of employment.

3. A bachelors (or higher) degree in a health related field preferred.

Security Requirements
This position is identified as level three (3). This position must ensure the security
and confidentiality of records and information to prevent substantial harm, embarrassment,
inconvenience, or unfairness to any individual on whom information is maintained.
The integrity of information must be maintained as outlined in the company Administrative
Manual.

Segregation of Duties
Segregation of duties will be used to ensure that errors or irregularities are prevented
or detected on a timely basis by employees in the normal course of business. This
position must adhere to the segregation of duties guidelines in the Administrative
Manual.

PRINCIPAL ACTIVITIES OR ACCOUNTABILITIES (Essential Functions of Job)1. Facilitate appropriate cost effective and cost containment measures.
2. Adhere to URAC Management Standards.
3. Practice case care management within the scope of licensure.
4. Cooperate and work effectively with all departmental staff to facilitate services to members and providers of care.
5. Remain current with medical and surgical procedures, products, services, and drugs by attending conferences, home studies, and in-services.
6. Monitor effective claims adjudication based on guidelines for contracted services.
7. Participate in quality improvement program.
8. Prompt case findings which are essential to assure timely transfer to lower levels of care.
9. Work closely with hospital discharge planners and home care providers to establish plan,
identify the appropriate setting, including necessary equipment is in place and operational,
and providers being available upon discharge.
10. Contact member and physician explaining case management services, ensuring that all
parties involved agree to voluntary case management services.
11. Monitor contracted and case by case negotiations with providers for quality of care
issues, cost effectiveness, accessibility, and levels of services provided utilizing JCACHO
providers when possible.
12. Must be able to maintain a minimum patient caseload of at any given time and
manage appropriately.
13. Work referrals daily.
14. Maintain continuous, effective communication with internal and external vendors.